Tensionable knotless anchors and methods of tissue repair

ABSTRACT

Surgical devices and methods of soft tissue repair using pre-looped tensionable and non-pre-looped tensionable knotless fixation devices. A flexible material (for example, suture or suture tape) may be attached to the fixation device. A flexible material may be threaded through an eyelet of a tip provided as part of a swivel anchor assembly to provide added stability to the fixation devices.

RELATED APPLICATION

This is a divisional of U.S. application Ser. No. 15/352,246, filed onNov. 15, 2016, which is a continuation-in-part of U.S. application Ser.No. 15/004,154, filed on Jan. 22, 2016, now U.S. Pat. No. 10,172,606,the subject matter of which are herein incorporated by reference intheir entireties.

BACKGROUND

The present disclosure relates to surgical devices and methods and, moreparticularly, to surgical devices and methods for use in tissue repair.

SUMMARY

Surgical assemblies, systems and techniques for knotless soft tissuerepair and fixation, such as fixation of soft tissue (ligament, tendon,graft, etc.) to bone, are disclosed. Surgical assemblies comprisetensionable knotless fixation devices that are inserted into bone. Atensionable knotless fixation device is provided with a tensioningconstruct (formed of a tensioning strand, a tensionable, adjustable,knotless, self-cinching loop, and a splice adjacent the loop) pre-loadedonto a fixation device. A flexible material (for example, suture orsuture tape) may be attached to a fixation device. A flexible materialmay be threaded through an eyelet of a fixation device.

Methods of soft tissue repair which do not require tying of knots andallow adjustment of both tension of suture and location of tissue withrespect to bone are also disclosed.

An exemplary method includes the steps of providing a first fixationdevice preloaded with a tensionable construct; providing a secondfixation device with a non-pre-looped tensionable construct; anchoringthe first and second fixation devices in bone such that the first andsecond fixation devices are arranged in a medial row; passing thepre-loaded tensionable construct of the first fixation device and thenon-pre-looped tensionable construct of the second fixation devicethrough tissue; threading a free end of a flexible strand of thenon-pre-looped tensionable construct through a tensionable loop of thepre-looped tensionable construct and then subsequently passing the freeend of the non-pre-looped tensionable construct through an eyelet of apassing device coupled with the flexible strand of the non-pre-loopedtensionable construct; and pulling on a tail end of the passing deviceto thread the free end of the flexible strand of the first fixationdevice through a splice in itself, thereby forming two interlockingloops outside of the tissue. This exemplary method may also include thesteps of preloading the first and second fixation devices with first andsecond flexible materials, respectively; passing first and second limbsof the first and second flexible materials through the tissue proximalto the pre-looped tensionable and non-pre-looped tensionable constructs;tightening or tensioning the two interlocking loops by pulling on a freeend of the pre-looped tensionable construct and the free end of thenon-pre-looped tensionable construct; and securing the first and secondends of the first and second flexible material to bone with additionalfixation devices.

Other objects, advantages and salient features of the invention willbecome apparent from the following detailed description, which, taken inconjunction with the annexed drawings, discloses preferred embodimentsof the present invention.

BRIEF DESCRIPTION OF THE DRAWINGS

FIGS. 1 and 2 illustrate an exemplary embodiment of a fixation deviceloaded onto a driver.

FIGS. 3 and 4 illustrate an exemplary embodiment of an anchor tip loadedwith a tensioning construct.

FIGS. 5-8 illustrate an exemplary embodiment of an anchor tip.

FIGS. 9-11 illustrate another exemplary embodiment of an anchor tip (a3.5 mm round eyelet).

FIGS. 12-14 illustrate another exemplary embodiment of an anchor tip (a4 mm round eyelet).

FIGS. 15-18 illustrate another exemplary embodiment of an anchor tip (anelongated open eyelet, curved).

FIGS. 19A-19D illustrate an exemplary embodiment of a surgical assembly.

FIGS. 20-30 illustrate an exemplary method of tissue repair with thefixation device of FIG. 1 .

FIGS. 31A-B illustrate pre-looped and non-pre-looped tensionablefixation devices in accordance with an exemplary embodiment of thepresent invention.

FIGS. 32A-32D illustrate exemplary method of tissue repair using thefixation devices of FIGS. 31A-31B.

FIGS. 33A-33C illustrate another exemplary method of tissue repair usingthe fixation devices of FIGS. 31A-31B.

FIGS. 34A and 34B illustrate a further exemplary method of tissue repairwith the tensionable fixation device of FIGS. 31A-31B.

FIG. 35 illustrates a driver and anchor assembly.

FIGS. 36A and 36B illustrates a pre-looped tensionable loop assembly anda non-pre-looped tensionable loop assembly, respectively.

FIGS. 37A and 37B, and FIGS. 37C and 37D, illustrate an anchor constructas a pre-looped tensionable loop construct, depicted after the anchorhas been inserted into the bone, and an anchor construct that isnon-pre-looped tensionable loop construct, depicted after the anchor hasbeen inserted into the bone, respectively.

DETAILED DESCRIPTION

Surgical assemblies, systems and techniques for knotless soft tissuerepair and fixation, such as fixation of soft tissue (ligament, tendon,graft, etc.) to bone, are disclosed. Surgical assemblies comprisetensionable knotless fixation devices that are inserted into bone.Tensionable knotless fixation devices are provided with a tensioningconstruct (formed of a tensioning strand, a tensionable, adjustable,knotless self-cinching loop, and a splice adjacent the loop) pre-loadedonto the fixation device. A flexible material (for example, suture orsuture tape) may be attached to the fixation device, for example, bybeing threaded through an eyelet of the fixation device.

As detailed below, the surgical assemblies and devices disclosed allowfor knotless fixation of tissue using an eyelet suture of a fixationdevice (for example, a suture anchor with an eyelet or a SwiveLock®anchor). A mechanism inside the suture eyelet is similar to the knotlesstensionable construct of the SutureTak®, except that there is no post orsimilar device within the anchor body to allow suture to wrap around.The knotless tensionable construct passes the anchor body of modifiedSwiveLock® anchors. In this manner, the surgical assemblies and devicesdetailed below combine two technologies to provide a strong knotlessrepair, as well as a backup knotless repair separate from a firstrepair.

Methods of soft tissue repair which do not require tying of knots andallow adjustment of both the tension of the suture and the location ofthe tissue with respect to the bone are also disclosed.

A surgical assembly can include (i) a fixation device; (ii) atensionable construct pre-loaded on the fixation device; and (iii) aflexible material (for example, suture or suture tape) attached to thefixation device. A flexible material may be also pre-loaded on thefixation device, and may be releasably attached to the fixation device,or securely fixed to it. The fixation device can include an anchor bodyinsertable over an anchor tip, the anchor tip including a shaft attachedto an anchor tip body, the anchor tip body being provided with first andsecond apertures or openings (for example, an eyelet oriented in a firstdirection and a through-hole or passage oriented in a second direction,which may be different from the first direction). A tensionableconstruct may be pre-loaded on the fixation device. The tensionableconstruct may consist of a flexible strand with a knot and a free end, asplice and an adjustable, tensionable, self-cinching, knotless, closedloop having an adjustable perimeter, located adjacent the splice. Thetensionable construct passes through the anchor tip and extends throughat least a portion of the anchor body of the fixation device.

The fixation device may be a SwiveLock® anchor as disclosed anddescribed, for example, in U.S. Pat. No. 8,012,174 issued Sep. 6, 2011,U.S. Pat. No. 9,005,246 issued Apr. 14, 2015, and US 2013/0296936published Nov. 7, 2013, the disclosures of all of which are fullyincorporated by reference in their entirety herein, with or without amodified eyelet in the anchor tip, and as detailed below.

The flexible material (suture construct) can be any suture strand orsuture tape, for example, Arthrex FiberTape®, which is a high strengthsuture tape that is braided and rectangular-like in cross section and asdisclosed in U.S. Pat. No. 7,892,256, the disclosure of which isincorporated by reference in its entirety herein. However, the fixationdevices detailed below can be used with any type of flexible material orsuture known in the art.

The tensionable construct may use a mechanism similar to that ofknotless SutureTak® but provides variations and improvements in thedesign of the tensioning construct. Details of the formation of anexemplary tensioning construct employed in the embodiments of thepresent invention detailed below are set forth in U.S. Pat. No.9,107,653 issued Aug. 18, 2015; US 2013/0165972, entitled “TensionableKnotless Anchor Systems and Methods of Tissue Repair;” and US2013/0345750, entitled “Tensionable Knotless Labral Anchor and Methodsof Tissue Repair,” the disclosures of all of which are incorporated byreference in their entirety herein.

The tensionable construct may be formed of a flexible strand or flexiblematerial that is easily spliced through itself to form a splice and aknotless, self-cinching, adjustable, closed loop with an adjustableperimeter. The flexible strand or material may be made of any knownsuture material, such as ultrahigh molecular weight poly ethylene(UHMWPE) or FiberWire® suture (disclosed in U.S. Pat. No. 6,716,234 thedisclosure of which is herein incorporated by reference in itsentirety), and can be braided or multi-filament. For example, the suturecan be UHWMPE suture without a core to permit ease of splicing.

FIG. 1 illustrates an exemplary embodiment of a fixation device 10(tensionable knotless fixation device 10) seated on a driver 91.Tensionable knotless fixation device 10 comprises an anchor body 20 andan anchor tip 30, the anchor body 20 being insertable over the anchortip 30. A tensionable construct 50 (also referred to as “tensioningconstruct 50”) and a flexible material 70 are pre-loaded on the fixationdevice 10 to form surgical assembly 1. Tensionable knotless fixationdevice 10 is seated on driver 91. Driver 91 has a thin cannulated rod92, where anchor tip 30 is seated at the proximal end 94 of the thincannulated rod 92. Anchor body 20 is cannulated and is fully seatedaround thin cannulated rod 92.

Tensionable construct 50 is pre-loaded onto the fixation device 10, andextends through at least a portion of the fixation device. Flexiblematerial 70 may be also pre-loaded onto the fixation device 10.

Anchor tip 30 includes anchor tip body 31 attached to a cannulated shaft36 (not shown in FIG. 1 ), wherein the cannulated shaft 36 is at leastpartially disposed within thin cannulated rod 92 of driver 91. Anchortip body 31 is also provided with first and second through-holes,openings, or passages 32, 34. In an exemplary embodiment, one of thefirst and second through-holes, openings, or passages is an eyelet 32having a first orientation relative to a longitudinal axis of the anchortip, and the other of the first and second-through holes, openings, orpassages is a flexible material hole or passage 34 (a transverse opening34) having a second orientation relative to a longitudinal axis of theanchor tip. In an exemplary embodiment, the first orientation isdifferent from the second orientation. In another exemplary embodiment,the first orientation is about perpendicular to the second orientation.Eyelet 32 accommodates and houses tensionable construct 50. Hole,opening, or passage 34 accommodates and houses flexible material 70.

FIG. 2 illustrates another view of tensionable knotless fixation device10 pre-loaded with tensionable construct 50 but without flexiblematerial 70.

During installation of fixation device 10, anchor body 20 is assembledonto the operational end of the driver 91. Anchor tip 30 is threaded orotherwise attached onto the tip of thin cannulated rod 92. Anchor tip 30is then placed within a prepared bone hole or tunnel until anchor tip 30reaches the bottom of the bone hole or tunnel, or reaches the desireddepth. At this point, anchor body 20 is still outside of the bone holeor tunnel. Anchor body 20 is then reduced down thin cannulated rod 92(advanced down the cannulated rod to be insertable over the anchor tip30) by holding a thumb pad (not pictured) as the inserter handle (notpictured) of the driver 91 is turned clockwise. When anchor body 20 isfully seated, cannulated shaft 36 of anchor tip 30 is fully engaged bycannulated anchor body 20, creating a stable swivel construct of thefixation device 10 wherein anchor tip 30 is rotatably secured to anchorbody 20.

In an exemplary embodiment, anchor body 20 is cannulated and has aproximal end 22 and a distal end 24, wherein proximal end 22 is the endclosest to anchor tip 30. The exterior 26 of anchor body 20 can bethreaded, for example like a screw, or can be any suitable means forsecuring in a bone hole or tunnel, for example, in the form ofcircumferential ridges extending radially. The exterior 26 of anchorbody 20 is responsible for both securing fixation device 10 in the bonehole or tunnel, as well as securing, by friction or interference fit,suture construct 70 against the bone wall and exterior 26 of anchor body20.

Anchor body 20 (in the form of a cannulated fixation device 20 orcannulated screw 20) may be pre-loaded onto the shaft of the driver. Theanchor tip 30 (implant 30) is designed to be releasably attached (by asnap fit, for example) to a distal end of the driver and to swivelrelative to the anchor body 20 (cannulated fixation device 20). Theanchor tip (implant) with attached suture is anchored into bone byrotating the driver to rotate and advance the anchor body 20 (cannulatedfixation device 20) while keeping the anchor tip 30 (implant 30)stationary, thereby securing the suture and providing tissue fixationwithout tying knots in the suture. The driver with the cannulated rod(passing slidably and rotatably through a cannulated driver assembly ofthe driver) has a tip adapted to accept the anchor tip 30 (implant 30),to allow the anchor tip 30 to be loaded onto the rod and be fully seatedon an end of the shaft of the driver.

The anchor tip 30 (implant 30) is rotatably received within the anchorbody 20 upon advancement of the anchor body 20 over a shaft of theanchor tip 30, the anchor tip 30 being configured to receive thetensionable construct and the flexible material. The anchor tip has aclosed aperture or eyelet to receive the flexible material (suture orsuture tape) to be attached to bone. The anchor tip 30 may be a metaltip or non-metal tip (e.g., plastic or polymer), and the anchor body 20may have a cylindrical, screw-like configuration (for example, acannulated interference screw).

Flexible material 70 can comprise any type of flexible material orsuture known in the art, preferably suture tape such as ArthrexFiberTape®, or combination of suture and suture tape, among many others.Flexible material 70 can be configured to be pre-loaded or threadedthrough eyelet 32 of anchor tip 30. A first limb 72 a and a second limb72 b pass outside of anchor body 20 and are secured against the bonewall and exterior 26 by friction or interference fit. In an exemplaryembodiment, first limb 72 a and second limb 72 b can terminate into asingle suture passing limb 74 to simplify passing each of limbs 72 a and72 b through tissue. In this manner, both limbs 72 a and 72 b can bepassed at the same time. After passing limb 74 is passed through tissue,it can be cut and removed, leaving first limb 72 a and second limb 72 bseparated and passed through tissue.

In another embodiment, first limb 72 a and second limb 72 b do notterminate into a single passing limb, and are passed through tissueseparately. In this embodiment, flexible material 70 may or may not bepre-loaded through eyelet 32 of anchor tip 30. In another embodiment,first limb 72 a and second limb 72 b do not terminate into a singlesuture passing limb, but both are loaded into a suture passer togetherand passed together.

FIG. 3 illustrates an exemplary embodiment of anchor tip 30 withtensionable construct 50 preloaded onto anchor tip 30. Tensionableconstruct 50 comprises a tensioning strand 52, a tensionable loop 54, asplice 55, and fixed loop strands 56 a and 56 b of stand 56 attached toloop 54. Fixed loop strands 56 a and 56 b pass through tensionable loop54 and can terminate into a single loop strand 56. Loop strand 56 andtensioning strand 52 can then terminate into a single tensioningconstruct passing limb 58. In another embodiment, loop strands 56 a and56 b do not terminate into a single loop strand 56, but insteadterminate along with tensioning strand 52 into tensioning constructpassing limb 58. In this embodiment, three limbs teiminate into one limbat the same place. Tensioning construct passing limb 58 can be passedthrough tissue and then cut and removed. Loop strands 56 a and 56 b canthen be discarded, leaving tensioning strand 52 and tensionable loop 54passed through the tissue. Multiple tensionable loop strands may beprovided attached to loop 54 (for example, passed through the loop 54).Loop 54 is a knotless, tensionable, adjustable, self-cinching loophaving an adjustable perimeter.

Tensionable construct 50 can be pre-loaded onto anchor tip 30 by tyingstatic knot 60 on the outside of hole 34. Tensioning strand 52,tensionable loop 54, splice 55, and loop strands 56 a and 56 b passthrough cannulated shaft 36 of anchor tip 30 and then through cannulatedanchor body 20, exiting fixation device 10 at distal end 24 of anchorbody 20. FIG. 4 illustrates loop strands 56 a, 56 b terminating intoloop strand 56, and then loop strand 56 and tensioning strand 52terminating into tensioning construct passing limb 58.

FIGS. 5-18 illustrate various exemplary embodiments 30 a-30 d of anchortip 30.

FIGS. 5-8 illustrate exemplary embodiment 30 a of anchor tip 30. Anchortip 30 a can include eyelet 32 a, hole 34 a, and cannulated shaft 36 a.Hole 34 a is positioned at the proximal tip of anchor tip 30 a.Cannulated shaft 36 a can have an outer width 37 a and an inner width 38a, where inner width 38 a represents how wide the hollow portion ofcannulated shaft 36 a is. In an exemplary embodiment, hole 34 a can bewider than the inner width 38 a. In another exemplary embodiment, hole34 a and inner width 38 a can be approximately the same width. Inanother exemplary embodiment, hole 34 a can be narrower than inner width38 a. Additionally, tip body 31 a can be wider than outer width 37 a ofcannulated shaft 36 a. Proximal end 33 a of anchor tip 30 a can be widerthan, about as wide as, or narrower than, outer width 37 a of cannulatedshaft 36 a. The size and shape of eyelet 32 a can be any suitable sizeand shape. In the exemplary embodiment of FIGS. 5-8 , eyelet 32 a hastwo rounded ends, wherein first rounded end 40 a, located near proximalend 33 a of anchor tip 30 a, is smaller than second rounded end 41 alocated near cannulated shaft 36 a.

FIGS. 9-11 illustrate another exemplary embodiment 30 b of anchor tip30. Anchor tip 30 b can include eyelet 32 b, hole 34 b, and cannulatedshaft 36 b. Hole 34 b is positioned at positioned at the proximal tip ofanchor tip 30 b. Anchor tip 30 b can further have a second hole 35 blocated on the side of anchor tip body 31 b. Cannulated shaft 36 b canhave an outer width 37 b and an inner width 38 b, where inner width 38 brepresents how wide the hollow portion of cannulated shaft 36 b is. Inan exemplary embodiment, hole 34 b can be wider than the inner width 38b. In another exemplary embodiment, hole 34 b and inner width 38 b canbe approximately the same width. In another exemplary embodiment, hole34 b can be narrower than inner width 38 b. Additionally, tip body 31 bcan be wider than outer width 37 b of cannulated shaft 36 b. Proximalend 33 b of anchor tip 30 b can be wider than, about as wide as, ornarrower than outer width 37 b of cannulated shaft 36 b. The size andshape of eyelet 32 b can be any suitable size and shape. In theexemplary embodiment of FIGS. 9-11 , eyelet 32 b has two rounded ends,wherein first rounded end 40 b, located near proximal end 33 b of anchortip 30 b, is smaller than second rounded end 41 b located nearcannulated shaft 36 b.

FIGS. 12-14 illustrate another example embodiment 30 c of anchor tip 30.Anchor tip 30 c can include eyelets 32 c, hole 34 c, and cannulatedshaft 36 c. Hole 34 c is positioned at positioned at the proximal tip ofanchor tip 30 c. Cannulated shaft 36 c can have an outer width 37 c andan inner width 38 c, where inner width 38 c represents how wide thehollow portion of cannulated shaft 36 c is. In an exemplary embodiment,hole 34 c can be wider than the inner width 38 c. In another exemplaryembodiment, hole 34 c and inner width 38 c can be approximately the samewidth. In another exemplary embodiment, hole 34 c can be narrower thaninner width 38 c. Additionally, tip body 31 c can be wider than outerwidth 37 c of cannulated shaft 36 c. Proximal end 33 c of anchor tip 30c can be wider than, about as wide as, or narrower than outer width 37 cof cannulated shaft 36 c. The size and shape of eyelets 32 c can be anysuitable size and shape. In the exemplary embodiment of FIGS. 12-14 ,eyelets 32 c each have an approximately rectangular shape.

FIGS. 15-18 illustrate another exemplary embodiment 30 d of anchor tip30. Anchor tip 30 d can include eyelet 32 d, hole 34 d, and cannulatedshaft 36 d. Hole 34 d can be located on the side of anchor tip body 31d. Cannulated shaft 36 d can have an outer width 37 d and an inner width38 d, where inner width 38 d represents how wide the hollow portion ofcannulated shaft 36 d is. Tip body 31 d can be wider than outer width 37d of cannulated shaft 36 d. Proximal end 33 d of anchor tip 30 d can bewider than, about as wide as, or narrower than outer width 37 d ofcannulated shaft 36 d. The size and shape of eyelet 32 d can be anysuitable size and shape. In the exemplary embodiment of FIGS. 15-18 ,eyelet 32 d has two rounded ends, wherein first rounded end 40 d,located near proximal end 33 d of anchor tip 30 d, is smaller thansecond rounded end 41 d located near cannulated shaft 36 d.

FIGS. 19A-D illustrate simplified steps of an exemplary surgical tissuerepair 100 with at least one exemplary fixation device described above.The exemplary surgical repair includes a medial row with first andsecond medial fixation devices 10 a and 10 b, and a lateral row withfirst and second lateral fixation devices 10 c and 10 d. First andsecond medial fixation devices 10 a and 10 b can be any embodiment offixation device 10 described herein, and can comprise anchor body 20,anchor tip 30, tensionable construct 50, and flexible material 70.

First and second lateral fixation devices 10 c and 10 d can be anysuitable knotless fixation devices known in the art. For example, firstand second lateral fixation devices 10 c and 10 d can be any embodimentof fixation device 10 described herein, or any Arthrex SwiveLock®anchors (as disclosed and described in U.S. Pat. No. 8,012,174 issuedSep. 6, 2011, U.S. Pat. No. 9,005,246 issued Apr. 14, 2015, and US2013/0296936 published Nov. 7, 2013, the disclosures of all of which arefully incorporated by reference in their entirety herein) or any ArthrexPushLock™ anchors (as described in U.S. Pat. No. 7,329,272 issued Feb.12, 2008, the disclosure of which is fully incorporated herein byreference), or any combination of these devices.

First and second lateral fixation devices 10 c and 10 d do not have atensioning construct or suture construct pre-loaded. Instead, first andsecond lateral fixation devices 10 c and 10 d are secured to thesurgical assembly by limbs 72 a, 72 b, 72 c, and 72 d of flexiblematerials 70 a and 70 b. A first limb 72 a of flexible material 70 a anda first limb 72 c of flexible material 70 b are passed through an eyelet(not pictured) of first lateral fixation device 10 c before the eyeletis loaded into a prepared bone tunnel or hole. Tension can be adjustedif necessary prior to advancing anchor body (not pictured) of lateralfixation device 10 c into the prepared bone tunnel or hole. A secondlimb 72 b of flexible material 70 a and a second limb 72 d of flexiblematerial 70 b are similarly passed through an eyelet (not pictured) ofsecond lateral fixation device 10 d before the eyelet is loaded into aprepared bone tunnel or hole. Tension can be adjusted if necessary priorto advancing anchor body (not pictured) of lateral fixation device 10 dinto the prepared bone tunnel or hole. First and second limbs 72 a and72 b of flexible material 70 a pass through tensionable loop 54 a andthus can be tensioned by pulling tensioning strand 52 a. Similarly,first and second limbs 72 c and 72 d of flexible material 70 b passthrough tensionable loop 54 b and can be tensioned by pulling tensioningstrand 52 b. Thus, the final surgical assembly of repair 100 (FIG. 19D)having four fixation devices is secured by flexible materials 70 a and70 b, while tensioning constructs 50 a and 50 b provide additionaltensioning capabilities in addition to providing a backup knotlessrepair separate from the repair by flexible materials 70 a and 70 b.

Methods of soft tissue repair utilizing the surgical assemblies anddevices described above are also disclosed. FIGS. 20-30 illustrate moredetailed steps of an exemplary embodiment of a tissue repair method toachieve final repair 200 (FIG. 30 ).

FIG. 20 illustrates target tissue 90 and bone 99 with two preparedmedial bone holes 111 and 112, with first tensionable knotless fixationdevice 10 a implanted into prepared medial bone hole 111. Fixationdevice 10 a has an anchor tip and anchor body (not visible since theyhave been implanted into prepared medial bone hole 111), tensionableconstruct 50 a, and flexible material 70 a. Tensionable construct hastensioning strand 52 a, tensionable loop 54 a, splice 55 a, and loopstrands 56 a and 56 b. Not pictured is the termination of the limbs intoa single tensioning construct passing limb. Flexible material 70 a hasfirst limb 72 a and second limb 72 b. Not pictured is the termination ofthe limbs into a single flexible material passing limb. Tissue 90 may besoft tissue such as rotator cuff, for example.

FIG. 21 illustrates the step of passing tensionable construct 50 athrough tissue 90 (for example, tendon, ligament, graft, etc.). In anexemplary embodiment, tensioning strand 52 a and loop strands 56 a and56 b terminate into a single tensioning construct passing limb 58 a.Tensioning construct passing limb 58 a is loaded into any suitablesuture passer known in the art, for example the Arthrex Scorpion™ suturepasser. Suture passer 120 is positioned in the desired location on thetarget tissue and tensioning construct passing limb 58 a is passedthrough target tissue 90. In embodiments where tensioning strand 52 aand loop strands 56 a and 56 b do not terminate into a single tensioningconstruct passing limb, then each strand may be passed separately, orloaded into a suture passer capable of passing multiple strandssimultaneously.

FIG. 22 illustrates tensioning construct passing limb 58 a passedthrough target tissue 90. Tensioning construct passing limb 58 a ispulled through target tissue such that tensioning strand 52 a andtensionable loop 54 a also pass through target tissue 90.

FIG. 23 illustrates the step of removing tensioning construct passinglimb 58 a from tensionable construct 50 a. Cutting tensioning constructpassing limb 58 a leaves three strands: loop strands 56 a, 56 b, andtensioning strand 52 a. Loop strands 56 a and 56 b wrap aroundtensionable loop 54 a and may be discarded. FIG. 24 illustratestensioning construct 50 a with tensioning strand 52 a and tensionableloop 54 a passed through tissue 90, and loop strands 56 a and 56 bhaving been discarded. First and second limbs 72 a and 72 b of flexiblematerial 70 a have not yet been passed through tissue 90.

FIG. 25 illustrates the step of passing flexible material 70 a throughtissue 90. In an exemplary embodiment, first and second limbs 72 a and72 b of flexible material 70 a can terminate into a single flexiblematerial passing limb 74 a. Passing limb 74 a is loaded into anysuitable suture passer known in the art, for example the ArthrexScorpion™ suture passer. Suture passer 120 is positioned at a locationon the target tissue adjacent or near where tensioning construct 50 awas passed, and passing limb 74 a is passed through target tissue 90. Inembodiments where first and second limbs 72 a and 72 b do not terminateinto a passing limb, then each limb may be passed separately, or loadedinto a suture passer capable of passing multiple limbs simultaneously.

FIG. 26 illustrates tensioning strand 52 a, tensionable loop 54 a, andfirst and second limbs 72 a and 72 b all passed through tissue 90.Passing limb 74 a has been cut and removed, leaving first and secondlimbs 72 a and 72 b separated.

FIG. 27 illustrates the step of retrieving first and second limbs 72 aand 72 b through tensionable loop 54 a. First and second limbs 72 a and72 b can be retrieved using any retriever known in the art, for examplethe Arthrex FiberTape® Retriever. After being loaded into retriever 130,limbs 72 a and 72 b are pulled through tensionable loop 54 a.

FIG. 28 illustrates the previously described steps having been repeatedand completed for a second medial fixation device 10 b. Second medialfixation device 10 b has an anchor tip and anchor body (not visiblesince they have been implanted into prepared medial bone hole 112),tensionable construct 50 b, and flexible material 70 b. Tensionableconstruct has tensioning strand 52 b, tensionable loop 54 b, splice 55b, and loop strands (not pictured since they have already beendiscarded). Flexible material 70 b has first limb 72 c and second limb72 d.

Once first and second medial fixation devices 10 a and 10 b have beenimplanted, and tensioning strands 52 a and 52 b, tensionable loops 54 aand 54 b, splices 55 a and 55 b, and limbs 72 a, 72 b, 72 c, and 72 dhave been passed through tissue 90, lateral bone holes can be preparedfor first and second lateral fixation devices 10 c and 10 d. Lateralfixation devices 10 c and 10 d can be any suitable fixation devices, forexample any embodiment of fixation device 10 described herein, or anyArthrex SwiveLock® anchors (as disclosed and described, for example, inU.S. Pat. No. 8,012,174 issued Sep. 6, 2011, U.S. Pat. No. 9,005,246issued Apr. 14, 2015, and US 2013/0296936 published Nov. 7, 2013, thedisclosures of all of which are fully incorporated by reference in theirentirety herein), or any Arthrex PushLock™ anchors (as described in U.S.Pat. No. 7,329,272 issued Feb. 12, 2008, the disclosure of which isfully incorporated herein by reference), or any screw-in or push-in typeanchors, or any combination of these devices.

First and second lateral fixation devices 10 c and 10 d do not have atensionable construct or flexible material (suture tape) pre-loaded.Instead, first and second lateral fixation devices 10 c and 10 d aresecured to the surgical assembly by limbs 72 a, 72 b, 72 c, and 72 d offlexible material 70 a and 70 b. First limb 72 a of flexible material 70a and a first limb 72 c of flexible material 70 b are passed through aneyelet (not pictured) of first lateral fixation device 10 c before theeyelet is loaded into a prepared bone hole. Tension can be adjusted ifnecessary prior to advancing anchor body (not pictured) of lateralfixation device 10 c into the prepared bone hole. Second limb 72 b offlexible material 70 a and a second limb 72 d of flexible material 70 bare similarly passed through an eyelet (not pictured) of the secondlateral fixation device 10 d before the eyelet is loaded into a preparedbone hole. Tension can be adjusted if necessary prior to advancinganchor body (not pictured) of lateral fixation device 10 d into theprepared bone hole.

After first and second lateral fixation devices 10 c and 10 d have beenfixated/inserted/implanted, the resulting surgical assembly is shown inFIG. 28 . Any remainder of limbs 72 a, 72 b, 72 c, and 72 d extendingout from lateral fixation devices 10 c and 10 d may be cut off using anysuitable suture cutter, for example the Arthrex FiberWire® cutter. FIG.28 also illustrates the step of pulling tensioning strand 52 a totighten tensionable loop 54 a in order to apply tension to first andsecond limbs 72 a and 72 b.

FIG. 29 illustrates the step of pulling tensioning strand 52 b totighten tensionable loop 54 b in order to apply tension to first andsecond limbs 72 c and 72 d of suture construct 70 b.

FIG. 30 illustrates the final surgical repair 200. Tensionable loops 54a and 54 b have been tensioned, and tensioning strands 52 a and 52 bhave been cut to remove them from the final assembly. Tensioning strands52 a and 52 b can be cut using any suitable suture cutter, for examplethe Arthrex FiberWire® cutter.

An exemplary method of tissue repair comprises inter alia the steps of:(i) inserting into bone a surgical assembly comprising a fixationdevice; a tensionable construct pre-loaded on the fixation device, thetensionable construct including a tensioning strand, a knotless,adjustable, self-cinching, tensionable loop having an adjustableperimeter, and a splice adjacent the loop; and a flexible material (forexample, suture tape) attached to the fixation device; and (ii) passingthe tensionable construct and limbs of the flexible material around orthrough tissue to be fixated (or reattached) to bone, so that thetensionable loop is positioned over the tissue, and then passing limbsof the flexible material through the tensionable loop. The method mayfurther comprise the step of securing the limbs of the flexible materialinto bone. The limbs may be secured with at least another fixationdevice that is inserted into bone. The method may further comprise thestep of pulling on the tensioning strand to appropriate tissue to bone.The tissue may be soft tissue such as tendon, ligament, or graft.

Another exemplary method of soft tissue repair comprises inter alia thesteps of: (i) inserting into bone a surgical assembly comprising afixation device; a tensionable construct pre-loaded on the fixationdevice, the tensionable construct including a tensioning strand, aknotless, adjustable, self-cinching, tensionable loop having anadjustable perimeter, and a splice adjacent the loop; and a flexiblematerial (for example, suture tape) attached to the fixation device;(ii) passing the tensionable construct and limbs of the flexiblematerial around or through tissue to be fixated (or reattached) to boneso that the tensionable loop is positioned above and over the softtissue, and above and over the bone; (iii) subsequently, passing limbsof the flexible material through the tensionable loop; and (iv) passingthe limbs of the flexible material over the tissue and securing thelimbs with additional fixation devices into bone, to form a mattressstich repair.

Another exemplary method of soft tissue repair comprises inter alia thesteps of: (i) inserting into bone a plurality of surgical assemblies,each surgical assembly comprising a fixation device; a tensionableconstruct pre-loaded on the fixation device, the tensionable constructincluding a tensioning strand, a knotless, adjustable, self-cinching,closed, tensionable loop having an adjustable perimeter, and a spliceadjacent the loop; and a flexible material (for example, suture orsuture tape) attached to the fixation device; (ii) passing thetensionable construct and limbs of the flexible material—of eachsurgical assembly—around or through tissue to be fixated (or reattached)to bone, so that the tensionable loop of each surgical assembly ispositioned over and above the soft tissue, and over and above the bone;(iii) subsequently, passing limbs of the flexible material of eachsurgical assembly through the corresponding tensionable loop; and (iv)passing the limbs of each surgical assembly over the tissue, andsecuring the limbs with a plurality of fixation devices into bone, toform a mattress stich repair.

The flexible strands and materials described above may be formed ofstrands of high strength suture material with surgically-usefulqualities, including knot tie down characteristics and handling, such asArthrex FiberWire® suture disclosed in U.S. Pat. No. 6,716,234, thedisclosure of which is incorporated by reference in its entirety herein.FiberWire® suture is formed of an advanced, high-strength fibermaterial, namely ultrahigh molecular weight polyethylene (UHMWPE), soldunder the tradenames Spectra (Honeywell) and Dyneema (DSM) fibers,braided with at least one other fiber, natural or synthetic, to formlengths of suture material. The flexible strand may be a high-strengthsuture, such as an ultrahigh molecular weight polyethylene (UHMWPE)suture which is the preferred material as this material allows easysplicing.

The suture constructs may be formed of optional colored strands, such asblack or blue, to assist surgeons in distinguishing between suturelengths with the trace and suture lengths without the trace. Preferably,each of the limbs may be provided in different colors to assist surgeonsin retrieving one limb from each of the knotless fixation devices andthen loading them through another knotless fixation device, during theformation of the criss-cross suturing pattern.

Suture constructs may be coated (partially or totally) with wax(beeswax, petroleum wax, polyethylene wax, or others), silicone,silicone rubbers, PTFE (Teflon, Hostaflon, or others), PBA (polybutylateacid), ethyl cellulose (Filodel) or other coatings, to improve lubricityof the suture or tape, knot security, pliability, handleability, orabrasion resistance, for example.

Suture constructs may also contain a bioabsorbable material, such asPLLA or one of the other polylactides, for example, and/or may be formedof twisted fibers having strands of a contrasting color added to thebraided threads, to make the suture more visible during surgicalprocedures. The colored strands can be dyed filaments or strands, forexample.

The surgical assembly and methods of the present invention haveapplicability to tissue repairs such as rotator cuff repair, Achillestendon repair, patellar tendon repair, knee repairs such as ACL and/orPCL reconstruction, hip and shoulder reconstruction procedures, andapplications involving repairing soft tissue to bone.

FIG. 31A illustrates a tensionable fixation device 102 with a pre-loadedtensionable loop (pre-looped tensionable fixation devices), and FIG. 31Billustrates another type of tensionable fixation device without apre-loaded tensionable loop (non-pre-looped tensionable fixation device)202 used in methods of tissue repair illustrated in FIGS. 32A-32D, FIGS.33A-33C, and FIGS. 34A and 34B, in accordance with various exemplaryembodiments as disclosed. The methods of FIGS. 32A-32D, 33A-33C, and 34Aand 34B are more secure than conventional knot repairs, are faster thanconventional repairs thus saving time and money in the OR, eliminate thepotential of knots impinging against adjacent structures and causingirritation or damage, and eliminate any knot failures of the repair.

As seen in FIG. 31A, the pre-looped tensionable suture anchor fixationdevice 102 that preferably includes an anchor body 120 that receives ananchor tip 130. The anchor tip 130 preferably includes an eyelet body132 having an eyelet 160 sized to receive a flexible member 170 (FIG.33A). The tensionable pre-looped suture anchor fixation device 102supports a tensionable construct 150 in a shaft 136 of the anchor body120. The tensionable pre-looped suture 150 may include a flexible strand152 and a pre-looped tensionable loop 154 spliced through a flexiblestrand 152. The flexible strand 152 may have a knotted end 156 thatengages the eyelet body 132 of the anchor tip 130 to prevent the strand152 from pulling through the anchor body 120, and a free end 158opposite the knotted end 156. Both the free end 158 and at least aportion of the tensionable loop 154 extend outside of the fixationdevice 102.

As seen in FIG. 31B, the non-pre-looped tensionable suture anchorfixation device 202 may include an anchor body 220 and an anchor tip 230(having an anchor tip body 232 and knotted end 256), similar topre-looped tensionable fixation device 102. The anchor tip 230 mayinclude an eyelet body 232 having an eyelet 160 sized to receive aflexible member 172 (FIG. 33A). The non-pre-looped tensionable sutureanchor fixation device 202 supports a non-pre-looped tensionableconstruct 250 in a shaft 236 within the anchor body 220. The-non-pre-looped tensionable suture construct 250 may include a flexiblestrand 252 that has a knotted end 256 engaging the eyelet body 232 ofthe anchor tip 230, and an opposite free end 258. The flexible strand252 is preferably coupled with a passer device 260. The passer device260 may be any known suture shuttling or puller that includes an eyelet262 and a tail end 264 opposite the eyelet 262. The passer device 260may be threaded through a splice in the flexible strand 252. The freeend 258 of the flexible strand 252 and both the eyelet 262 and tail end264 of the passer device 260 are outside of the anchor body 220.

FIGS. 32A-32D illustrate an exemplary method of tissue repair using thepre-looped and non-pre-looped tensionable fixation devices 102 and 202of FIGS. 31A and 31B, respectively. As seen in FIG. 32A, the pre-loopedand non-pre-looped tensionable fixation devices 102 and 202 arepreferably pre-loaded with constructs 150 and 250, respectively, and areanchored in bone 99, preferably in a medial row. The tensionableconstruct 150 of the pre-looped tensionable fixation device 102 ispassed through a target area in the tissue 90 (soft tissue layer). Theconstruct 250 of the non-pre-looped tensionable fixation device 202 ispassed through another target area in the tissue 90. Once passed throughthe tissue 90, the pre-looped tensionable loop 154 (or a portionthereof) and the free end 158 of the pre-looped tensionable construct150, and the free end 258, the passer device eyelet 262 and tail end 264of the non-pre-looped tensionable construct 250, are above or outside ofthe tissue 90. A cannula 300 may be optionally provided to facilitatemanagement of the constructs 150 and 250.

Once the constructs 150 and 250 are passed through the tissue 90,interlocking loops are formed by first threading the free end 258 of thenon-pre-looped tensionable construct 250 through the tensionable loop154 of the tensionable pre-threaded construct 150 and then threading thefree end 258 back through the eyelet 262 of the passer device 260 of thenon-pre-threaded tensionable construct 250, as seen in FIG. 32B. Thetail end 264 of the passer device 260 can then be pulled away from therepair to thread the free end 258 of the strand 252 through itself (asshown by arrows in FIG. 32B), thereby forming two interlocking loops, asseen in FIG. 32C. Those loops may then be tightened by pulling on thefree ends 158 and 258, as seen in FIG. 32C, thereby providing a securesuture on the tissue repair.

FIG. 32D illustrates an optional step of further securing the free ends158 and 258 of the constructs 120 and 250, respectively, once tightenedon the repair, by employing additional fixation devices 302 to fix thefree ends 158 and 258 to bone 99. The additional fixation devices 302may be any known fixation device, such as SwivelLock C suture anchors.Cinch-loop sutures (90) may be placed and fixed to the lateral rowanchor to eliminate dog ears. The fixation devices 302 are preferablyarranged in a lateral row so that the free ends 158 and 258 of theconstructs 120 and 250 may cross one another and be secured via fixationdevices 302 to form a suture bridge that links the medial row of sutureanchors to the lateral row of suture anchors.

FIGS. 33A-33D illustrate another exemplary method of tissue repair usingthe tensionable and non-tensionable fixation devices 102 and 202 of FIG.31 and incorporating flexible materials 170 and 172. As seen in FIG.33A, once the fixation devices 102 and 202 are anchored to bone 99 andthe constructs 150 and 250 are passed through the tissue 90, the limbs170 a and 170 b of flexible material 170 may be passed through thetissue 90 proximal to the tensionable construct 150, and the limbs 172 aand 172 b of flexible material 172 may be passed through the tissue 90proximal to the non-tensionable construct 250. As seen in FIG. 33B, twointerlocking loops of the constructs 150 and 250 are formed in the samemanner as disclosed above regarding the embodiment of FIGS. 32A-32D. Thelimbs 170 a, 170 b of flexible material 170 and limbs 172 a, 172 b offlexible material 172 may be passed through the tissue either before orafter the interlocking loops of the constructs 150 and 250 are formedand are preferably passed through the tissue before the interlockingloops of the constructs 150 and 250 are fully tensioned or tightened.Once the interlocking loops of the constructs 150 and 250 are fullytensioned to form a load sharing rip-stop on the repair, the limbs 170a, 170 b of flexible material 170 and limbs 172 a, 172 b of flexiblematerial 172 may be pulled over the rip-stop of constructs 150 and 250to be secured to additional fixation devices 302 anchored in bone 99. Inthis embodiment, the flexible materials 170 and 172, such as suturetape, act as the primary securing sutures for the tissue repair. Theadditional fixation devices 302 may be arranged in a lateral row in bone99 and the limbs 170 a, 170 b of flexible material 170 and limbs 172 a,172 b of flexible material 172 may cross one another to form a bridge tocompress the underlying tissue against the bone. For example, the limb170 a and the limb 172 a may be secured to one of the additionalfixation devices 302 and the limb 170 b and the limb 172 b may besecured to the other of the additional fixation devices 302, as seen inFIG. 33C.

FIGS. 34A and 34B illustrate yet another exemplary method of tissuerepair using two tensionable fixation devices 150. Unlike theembodiments of FIGS. 32A-32D and 33A-33C, the embodiment of FIGS. 34Aand 34B do employ a tensionable fixation device. As seen in FIG. 34A,two of tensionable fixation devices 102 are preloaded with constructs150 and anchored in bone 99 and the constructs 150 are passed throughthe tissue 90. The tensionable loops 154 of each construct 150 arepassed separately though two different target areas in the tissue 90 andthen tied together with a knotted segment 304. A cannula 300 may be usedto facilitate management of the constructs 150 outside of the tissue 90.Once the loops 154 are tied together, they are brought down or over thetissue 90 by pulling on the free ends 158 and 258 of the tensionableconstructs 150, as seen in FIG. 34B. The knotted segment 304 preferablyremains in an open loop, thereby facilitating sliding of the interlinkedloops 154 on each other as the loops are tensioned.

FIG. 35 illustrates a driver and anchor assembly construct. A thumb pad302 is located below the handle 304 of the assembly construct. Theassembly construct includes a reverse threaded sleeve 300, which servesto drive an anchor body 120, such as a screw-in anchor body (such as aSwiveLock anchor), into a solid surface, such as into a bone. Located onthe eyelet body 180 is a hole 156, through which a knotted suture 256will exit. The knotted suture 256 functions to fix a distal end of atensionable suture loop to the anchor body 120. A tensionable sutureloop as part of the assembly construct may be provided by including apre-threaded tensionable suture loop, so as to provide a constructassembly having a “pre-looped” tensionable loop. Alternatively, atensionable loop that is not pre-threaded may be included with theassembly construct, so as to provide a “non-pre-looped” tensionable loopversion of the assembly construct. In the non-pre-looped tensionableloop construct assembly configuration, the tensionable loop will beformed after the anchor body 120 has been inserted into a surface, suchas inserted into bone. The driver and anchor body assembly would take onthe same general appearance in both the pre-looped and non-pre-loopedtensionable loop construct assembly. A knotted suture end 256 exiting ahole 156 in the side of the eyelet body 180 of the tip 190, serves tofix a distal strand of a tensionable loop (either pre-looped ornon-pre-looped tensionable loop construct), to the anchor body 120. Aneyelet 160 is provided within the eyelet body 180 of the tip 190.

FIG. 36A illustrates a pre-looped tensionable loop assembly 150 and FIG.36B illustrates a non-pre-looped tensionable loop assembly 250. Thepre-looped tensionable loop assembly 150 includes a tensionable loop 154that has been pre-threaded through a splice region 155. A knotted sutureend 156 at the eyelet body 180 serves to fix the distal strand of thetensionable loop 154 within a suture anchor.

FIG. 36B illustrates the non-pre-looped tensionable loop assembly 250that includes a looped end 262 of a passing strand 210 (passing strandmay be a FiberLink passer strand or a Nitinol wire passer strand). Thefree end 264 of the passing strand 300 and the main fixation suture limb258 are provided as part of the non-pre-looped tensionable loopassembly. The main fixation suture limb 258 will be threaded through asplice region 255 of the suture after passing the suture limb 258through the soft tissue that is to be secured. A knotted suture end 256at the eyelet body 180 serves to fix a distal end of the tensionableloop once formed

FIG. 37A illustrates the suture anchor and tensionable loop (pre-loopedtensionable loop version) construct configuration after the sutureanchor 150 has been inserted into a surface, such as into a bone. FIG.37B presents the eyelet body 130 that includes an eyelet 132, throughwhich a suture limb 170 is passed. Also depicted is the knotted sutureend 156 present on the suture body 130.

FIG. 37C illustrates the suture anchor and tensionable loop(non-pre-looped tensionable loop version) construct configuration 250after the suture anchor 220 has been inserted into a surface, such asinto a bone. The main fixation suture 258 will be threaded through thesplice region 255 of the suture 252, after the main fixation suture ispassed through or around an adjacent or surrounding penetrable material,such as through or around a soft tissue. The free passing end 264 of thepassing strand is shown extending out of the suture anchor shaft 350 ofthe suture anchor 220. The looped end 262 of the passing strand is alsoshown extending out of the suture anchor shaft 350 of the suture anchor220. The passing strand may be of a FiberLink passer material or anitinol wire passer material. An eyelet 232 is provided at a tip 190provided as part of the construct configuration, and includes an eyeletbody 230. Located on the eyelet body 230 is a knotted suture end 256.FIG. 37D—illustrates a detailed view of the tip 190. The tip 190 isshown to include an eyelet body 230 and an eyelet 232, through which asuture 172 may be passed. A knotted suture end 256 is shown at theeyelet body 230. The knotted suture end 256 of the passing suture strandserves to fix the distal end of the tensionable loop, and to maintain acontinued tension between the suture and suture anchor after the sutureanchor is implanted. This continued tension serves to enhance theself-locking mechanism at the suture splice 255.

A surgical kit is disclosed that may include one or more of the fixationdevices 102 and 202 preloaded with the tensionable pre-looped andtensionable non-pre-looped constructs 150 and 152, respectively. One ormore of the additional fixation devices 302 may also be provided withthe kit along with the optional cannula 300.

While particular embodiments have been chosen to illustrate theinvention, it will be understood by those skilled in the art thatvarious changes and modifications can be made therein without departingfrom the scope of the invention as defined in the appended claims.

What is claimed is:
 1. A method of knotless tissue repair, comprisingthe steps of: providing a first fixation device with a first tensionableconstruct that has a tensionable loop; providing a second fixationdevice with a non pre looped second tensionable construct; anchoring thefirst and second fixation devices in bone such that the first and secondfixation devices are arranged in a medial row; passing the firsttensionable construct of the first fixation device and the secondtensionable construct of the second fixation device through tissue;threading a free end of a flexible strand of the second tensionableconstruct through the tensionable loop of the first tensionableconstruct and then subsequently threading the free end of the secondtensionable construct through an eyelet of a passing device coupled withthe flexible strand of the second tensionable construct; pulling on atail end of the passing device opposite the eyelet thereof to thread thefree end of the flexible strand of the second tensionable constructthrough a splice in the second tensionable construct, thereby formingtwo interlocking loops outside of the tissue; and tightening the twointerlocking loops by pulling on a free end of the first tensionableconstruct and the free end of the second tensionable construct.
 2. Themethod of claim 1, wherein the free ends of the first and secondtensionable constructs are pulled sequentially to tighten the twointerlocking loops.
 3. The method of claim 1, further comprising thestep of securing the free ends of the first tensionable and secondtensionable constructs in bone with third and fourth fixation devices,respectively.
 4. The method of claim 3, further comprising the steps of:arranging the third and fourth fixation devices in a lateral row; andcoupling the free ends of the first tensionable and second tensionableconstructs to the third and fourth fixation devices to form a bridge. 5.The method of claim 1, further comprising the steps of: prethreadingdistal eyelets of the first and second fixation devices with first andsecond flexible materials, respectively, each of the first and secondflexible materials having first and second limbs; and passing the firstand second limbs of the first and second flexible materials through thetissue proximal to the first tensionable and second tensionableconstructs, respectively.
 6. The method of claim 5, wherein the step ofprethreading the distal eyelets of the first and second fixation deviceswith first and second flexible materials includes threading the firstand second flexible materials through eyelets of the first and secondfixation devices, respectively.
 7. The method of claim 5, wherein thetwo interlocking loops are tightened after passing the first and secondlimbs of the first and second flexible materials through the tissue. 8.The method of claim 7, further comprising the step of securing the firstand second ends of the first and second flexible material to bone withthird and fourth fixation devices.
 9. The method of claim 8, furthercomprising the steps of: arranging the third and fourth fixation devicesin a lateral row; and coupling the first limb of the first flexiblematerial and the first limb of the second flexible material to the thirdfixation device and coupling the second limb of the first flexiblematerial and the second limb of the second flexible material to thefourth fixation device to form a bridge.
 10. The method of claim 1,further comprising the step of passing the first tensionable and secondtensionable constructs through a cannula after passing the firsttensionable and second tensionable constructs through the tissue tofacilitate management of the constructs outside of the tissue.
 11. Amethod of knotless tissue repair, comprising the steps of: providing afirst fixation device with a first tensionable construct that has atensionable loop; providing a second fixation device with a secondtensionable construct; anchoring the first and second fixation devicesin bone such that the first and second fixation devices are arranged ina medial row; passing the first tensionable construct of the firstfixation device and the second tensionable construct of the secondfixation device through tissue; threading a free end of a flexiblestrand of the second tensionable construct through the tensionable loopof the first tensionable construct and then subsequently threading thefree end of the second tensionable construct through an eyelet of apassing device coupled with the flexible strand of the secondtensionable construct; pulling on a tail end of the passing deviceopposite the eyelet thereof to thread the free end of the flexiblestrand of the second tensionable construct through a splice in thesecond tensionable construct, thereby forming two interlocking loopsoutside of the tissue; and passing the first tensionable and secondtensionable constructs through a cannula after passing the firsttensionable and second tensionable constructs through the tissue tofacilitate management of the constructs outside of the tissue.